Effects of air pollution and habitual exercise on the risk of death: a longitudinal cohort study

Background:Exercise may exacerbate the adverse health effects of air pollution by increasing the inhalation of air pollutants. We investigated the combined effects of long-term exposure to fine particle matter (PM_2.5) and habitual exercise on deaths from natural causes in Taiwan.Methods:We recruited 384 130 adults (aged ≥ 18 yr) with 842 394 medical examination records between 2001 and 2016, and followed all participants until May 31, 2019. We obtained vital data from the National Death Registry of Taiwan. We estimated PM_2.5 exposure using a satellite-based spatiotemporal model, and collected information on exercise habits using a standard self-administered questionnaire. We analyzed the data using a Cox regression model with time-dependent covariates.Results:A higher level of habitual exercise was associated with a lower risk of death from natural causes, compared with inactivity (hazard ratio HR] 0.84, 95% confidence interval CI] 0.80–0.88 for the moderate exercise group; HR 0.65, 95% CI 0.62–0.68 for the high exercise groups), whereas a higher PM_2.5 exposure was associated with a higher risk of death from natural causes compared with lower exposure (HR 1.02, 95% CI 0.98–1.07, and HR 1.15, 95% CI 1.10–1.20, for the moderate and high PM_2.5 exposure groups, respectively). Compared with inactive adults with high PM_2.5 exposure, adults with high levels of habitual exercise and low PM_2.5 exposure had a substantially lower risk of death from natural causes. We found a minor, but statistically significant, interaction effect between exercise and PM_2.5 exposure on risk of death (HR 1.03 95% CI 1.01–1.06). Subgroup analyses, stratified by PM_2.5 categories, suggested that moderate and high levels of exercise were associated with a lower risk of death in each PM_2.5 stratum, compared with inactivity.Interpretation:Increased levels of exercise and reduced PM_2.5 exposure are associated with a lower risk of death from natural causes. Habitual exercise can reduce risk regardless of the levels of PM_2.5 exposure. Our results suggest that exercise is a safe health improvement strategy, even for people residing in relatively polluted regions.

Air pollution and physical inactivity are both major public health challenges worldwide.¹ Air pollution was the fifth leading cause of disability related to health and accounted for 4.9 million deaths worldwide in 2017.² More than 91% of the global population lives in areas where air quality does not meet the World Health Organization (WHO) guidelines.³ In addition, physical inactivity was the fourth leading risk factor for death globally, accounting for 5.3 million deaths worldwide in 2012.⁴ The WHO has challenged its member states to reduce physical inactivity by 15% by 2030.⁵As people exercise, their ventilation rate increases, which increases the volume of air pollutants they inhale. This may exacerbate the adverse health effects of air pollutants. Thus, the risk–benefit relation between air pollution and exercise needs to be assessed to understand whether it is safe to exercise regularly in polluted regions. Indeed, some studies have shown that acute exposure to air pollution when exercising may override the benefits of exercise.^6,7 It is possible that the effects of long-term exposure to air pollution may be irreversible and cause a much larger disease burden than short-term exposure. Limited information exists on the combined effects of long-term exposure to air pollution and habitual exercise on human health, and findings have been inconsistent depending on health outcome. Three cohort studies have explored the relation between air pollution, physical activity and risk of death in Hong Kong,⁸ Denmark and the United States,⁹ with relatively small sample sizes.¹⁰ Therefore, we sought to investigate the combined effects of habitual exercise and long-term exposure to fine particle matter (PM_2.5) on the risk of death from natural causes (i.e., deaths not attributable to accident, suicide or homicide) using a longitudinal cohort of adults in Taiwan, where the annual PM_2.5 concentrations are 1.6 times higher than the WHO-recommended limit. We hypothesized that the beneficial effects of habitual exercise on risk of death may outweigh the risk of high levels of air pollutants inhaled during exercise.